Article Review: Early Identification of and Treatment for Borderline Personality Disorder

Sharp and Fonagy (2015) offer a review of the phenomenology, prevalence, etiology, clinical problems, and interventions for adolescents with BPD. Borderline personality disorder (BPD) is said to capture the core of personality pathology (Sharp & Fonagy, 2015). The symptoms of BPD usually manifest in adolescence (Chanen & Kaess, 2012, as cited in Sharp & Fogay, 2015); yet many clinicians are hesitant to diagnose personality pathology in children due to the presumed normal emotional liability during this developmental period. Interesting though, this period of turmoil has received only limited support in the research (Cicchetti & Rogosch, 2002, as cited in Sharp & Fonagy, 2015). Furthermore, a poor prognosis is often associated with individuals that have problems throughout adolescence, and as cited by Paris (2015), pathological symptoms greater than one year should not be dismissed and may likely be associated with BPD. Regardless, the symptoms of BPD compared to typical adolescence are often more severe, pervasive, long-standing, and reflected in both internalizing and externalizing disorders.

Sharp and Fonagy (2015) report that studies for early detection of BPD in adolescence have shown that “chronic feelings of emptiness and inappropriate, intense anger” are considered the “most stable symptoms,” whereas identity disturbance, affective instability, and intense anger have the “greatest predictive power for development of BPD” (p. 1268). These characteristics are said to be consistent across age groups. Additionally, for boys, paranoid ideation, and in girls, identity disturbance, have shown to be discriminating symptoms of BPD in adolescents. Persistent self-harm behaviors are known to distinguish BPD from other disorders. Similar to adults with BPD, risk factors in adolescents with BPD are general impulsivity, risky behaviors, difficulty dealing with stress, and negative affect. Impairment in social and academic functioning is also common.

As cited in Sharp and Fonagy (2015), Chanen & Kaess (2012) describe BPD as a developmental disorder. Research has indicated a mean age of onset at 18, with a standard deviation of 5- 6 years. Adolescence is said to be a critical period for the development of BPD due to the social demands (e.g., establishing stable friends, remaining close to family). Furthermore, the social and emotional development in adolescence is associated with functional and structural brain changes. While, BPD symptoms appear in adolescence, they are known to peak in early adulthood, with a decline in impulsive symptoms over time. Affective symptoms are more likely to persist. Sharp and Fonagy (2015) have shown evidence for heterotypic developmental course, meaning that there is “coherence in the underlying organization or meaning of behaviors over time” (p. 1271).

Regarding comorbidity, BPD in adolescence is highly associated with internalizing and externalizing disorders. Sharp and Fonagy (2015) cite that around 70% of adolescents with BPD have comorbid mood disorders, 67% have anxiety disorders, and 60% have externalizing disorders. Thus, the authors argue that BPD is a confluence of both externalizing and internalizing disorders, and is not a female expression of antisocial personality disorder. Additionally, there is evidence that constitutional factors (i.e., temperament) and environmental factors have a role in BPD etiology.

Yet, it is also difficult to distinguish BPD from other clinical disorders. For identification of BPD, several measures have shown clinical utility (See Sharp & Fonagy, 2015, for a more comprehensive review). Clinical assessment along with an objective measures is thought to be best clinical practice for precision in diagnosis. Regarding intervention, there is not a wealth of information available. Programs such as Helping Young People Early (HYPE) and Dutch Emotion Regulation Training (ERT) are early intervention efforts for BPD. They are based on cognitive analytic therapy and cognitive-behavioral elements and skills training, respectively. Cognitive-analytic therapy integrates psychoanalytic object relations theory and cognitive psychology and has demonstrated effectiveness and rapid recovery. Mentalization-based treatment for adolescents has similar components to cognitive analytic therapy and has shown effectiveness by “improved mentalizing and reduced attachment avoidance” (p. 1281). Dialectical behavior therapy (DBT) has also been adapted for treatment of BPD in adolescents. DBT targets emotional dysregulation, distress tolerance, and interpersonal difficulties. Transference-focused psychotherapy is grounded in object relations theory and has been adapted for adolescents, but has not underwent RCT to assess its effectiveness.

Sharp and Fonagy (2015) conclude that successful interventions should contain extensive efforts to maintain engagement in treatment, have an evidence-based model of developmental pathology, and have an active therapist role, with a focus on validation and modeling of empathy, as well as the development of a strong attachment. Additionally, there should be a facilitation of trust and belief that something can be learned in therapy. Treatment should focus on emotional processing and the connection between action and feelings, have structure to promote activity, proactivity, and self-agency, as well as be manualized, with supervision for deviations from the manual. There should be a commitment to the approach in treatment between both the therapist and client.

Evidence-based treatments for BPD have common treatment characteristics (Bateman, Gunderson, & Mulder, 2015). They are structured (manual directed) and they encourage clients to control themselves (agency). Therapists help connect feelings and actions and are active, responsive, and validating. They also discuss cases with others (i.e., supervision and/or consultation).

Overall, there is a delicate balance in assessing BPD in adolescents compared to recognizing the potential for emotional liability during this developmental period. Yet, understanding the clinical picture, as well as the distinguishing pervasive features of BPD, will help differentiate it from either normal turmoil and/or other disorders. Finally understanding treatment options can help clinicians gain confidence in identifying and providing subsequent treatment for adolescents with BPD.